Monday, April 23, 2018

No one will dispute that today’s
opioid epidemic is a crisis. Yesterday, the New York Times published an
extensive and thoughtful analysis of the situation and offered some prospective
solutions. Strangely, perhaps, the article appeared as an editorial.

Experts say that the death toll from opioids
could climb for years to come. Millions of people are dependent on or addicted
to these drugs, and many of them are increasingly turning to more potent,
illicit supplies of heroin and fentanyl, which are cheap and readily available
on the street and online. Yet only about 10 percent of Americans who suffer from substance abuse
receive specialized addiction treatment, according to a report by the surgeon
general.

The paper notes that we have been here before. In the late
19th century many Americans were addicted to morphine and opium. It adds that China suffered its own opium addiction crisis in the 19th
century. And, it’s worth mentioning, the British fought a war in China to keep
the nation addicted to opium from its colony in India. It was not the British Empire’s
finest hour.

One of
the more distressing truths of America’s opioid epidemic, which now kills tens
of thousands of people every year, is that it isn’t the first such crisis.
Across the 19th and 20th centuries, the United States, China and other
countries saw drug abuse surge as opium and morphine were used widely as
recreational drugs and medicine. In the West, doctors administered morphine
liberally to their patients, while families used laudanum, an opium tincture,
as a cure-all, including for pacifying colicky children. In China, many
millions of people were hooked on smoking opium. In the mid-1800s, the British
went into battle twice — bombing forts and killing thousands of civilians and
soldiers alike — to keep the Chinese market open to drug imports in what would
become known as the Opium Wars.

The Times continues:

As many
as 313,000 people were addicted to injected morphine and smoked opium in the
United States in the late 19th century, according to David Courtwright,
a history professor at the University of North Florida who has written
extensively about drugs. Another scholar, R. K. Newman, estimated that
as many as 16.2 million Chinese were dependent on opium and smoked the drug
daily.

We are not surprised to learn that the fault lies with our
medical community, with the pharmaceutical manufacturers who have been pushing the
drug, the physicians who have been prescribing it and the government
bureaucrats who downplayed the risk:

In the
19th century, like today, the medical community was largely responsible for the
epidemic. Doctors did not fully appreciate the risks these drugs posed. In the
1800s, many doctors viewed morphine as a wonder drug for pain, diarrhea, nerves
and alcoholism. In addition to getting homemakers, Civil War veterans and
others addicted, many doctors became addicts themselves. The drug was overused
in large part because there were few alternatives; aspirin, for example,
didn’t become available until the late 1890s.

It continues:

Today’s
opioid crisis has its roots in the 1990s, when prescriptions for painkillers
like OxyContin and Vicodin started to become common. Companies like Purdue
Pharma, which makes OxyContin, aggressively peddled the idea that these drugs
were not addictive with the help of dubious or misinterpreted research. One
short 1980 letter to The New England Journal of Medicine by
Dr. Hershel Jick and Jane Porter said the risk of addiction was less than one
percent, based on an analysis of nearly 12,000 hospital patients who were given
opioid painkillers. That letter was widely — and incorrectly — cited as
evidence that opioids were safe.

Surely, our government regulators should have known better.
They might, as the Times notes, have been swayed by the pharmaceutical companies,
but what is their job if not to evaluate the evidence… objectively. As for the
physicians, they will say that they were following the guidelines laid down in
scientific journals and accepted by government officials. But, couldn't they see the dangers in their own patients?

Federal
regulators, doctors and others were swayed by pharmaceutical companies that
argued for greater use of opioids; there was increasing awareness that doctors
had become too unresponsive to patients who were in pain. Patient advocates and
pain specialists demanded that the medical establishment recognize pain as
the “fifth vital sign.”

Mr. Courtwright
says that this was not a simple case of historical amnesia. In the earlier
epidemic, doctors “made mistakes, but it was a bad situation to begin with,” he
said. “There was no equivalent of Purdue Pharma flying you off to the Bahamas
for the weekend to tell you about the wonders of these new drugs.”

As for what can be done, the Times emphasizes
pharmacological solutions. On the lines of methadone clinics and greater
availability of a drug called buprenorphine. Happily, it does not pretend that
the addicts should all be in therapy. Congress and recent presidents have
failed to act:

Leaders
in both parties are responsible for this crisis. Presidents George W. Bush and
Barack Obama and members of Congress did too little to stop it in its earlier
stages. While Mr. Trump talks a lot about the problem, he seems to have few
good ideas for what to do about it. As we’ve learned the hard way, without
stronger leadership, the opioid epidemic will continue to wreak havoc across
the country.

And also:

Lawmakers
so far have fallen far short of such a vigorous effort when it comes to opioid
addiction. Congress has taken what can be considered only baby steps by
appropriating a total of a few billion dollars of discretionary opioid funding
in recent years. This funding amounts to a pittance relative to what is needed:
substantial long-term funding for prevention, addiction treatment, social
services and research. Andrew Kolodny, co-director of opioid policy research at
Brandeis University, says at least $6 billion a year is needed for 10 years to
set up a nationwide network of clinics and doctors to provide treatment with
medicines like buprenorphine and methadone. Those drugs have a proven track
record at reducing overdoses and giving people struggling with addiction a shot
at a stable life. Today, large parts of the country have few or no clinics that
offer medication-assisted treatment, according to an analysis
by amfAR,
a foundation that funds AIDS research.

Apparently, the bureaucrats who signed off on addictive
opioids are slow walking approval of buprenorphine. I will not offer a comment
on matters I know nothing about, but I will signal that France has used the
drug for more than two decades, reducing heroin overdoses:

Next,
lawmakers need to remove regulations restricting access to buprenorphine, an
opioid that can be used to get people off stronger drugs like heroin; its use
is unlikely to end in an overdose. Doctors who want to prescribe the drug have
to go through eight hours of training, and the government limits the number of patients they can treat.
These limits have made the drug harder to obtain and created a situation in
which it is easier to get the kinds of opioids that caused this crisis than to
get medicine that can help addicts. France reduced heroin overdoses by nearly
80 percent by making buprenorphine easily available starting in 1995.
Yet many American lawmakers and government officials have resisted removing
restrictions on buprenorphine, arguing it replaces one addiction with
another.

As I said, I am not qualified to offer an opinion about
pharmacological treatments of opioid addiction. I think that the Times has addressed
the problem seriously, to its credit. At the least, it has offered some
guidelines for addressing the problem. They are not the last word, but they
ought to provoke a serious discussion of what we can do.

You need to think about what the government response and the intimidation of physicians has done to people suffering from chronic severe pain. THeir lives have not been improved. People on maintenance doses of opiods can live normal lives.

Correct me if I am wrong but don’t the federal government and other regulating bodies withhold funding or otherwise punish hospitals when, during the review of the patient satisfaction surveys that patients are given, they see patients complaining that their pain was “not controlled as they expected?”

I am a RN at a large trauma center in the US. You would be stunned at the number of patients we get who tell us that we are supposed to get their pain down to a zero or, my personal favorite, “the surgeon promised me I wouldn’t have pain after open abdominal surgery!”

I thank God we have incredible pain meds - so many patients need them for very limited periods. Some may need them for chronic usage just to get through the day (cancer, RA, etc.). But the number of patients who know how to game the system is impressive.

We have to be careful suggesting that pain medicine INCREASES pain. When used properly, it helps patients tremendously, particularly post-surgical, post-trauma, kidney stones, gall bladder, etc.

But when someone has been on narcotics for an extended period of time, regardless of whether it is for legitimate or illegitimate purposes, the body requires more narcotic than it did in the past to achieve (hopefully) the same pain relief.

We simply could not do all the procedures and surgeries we do these days without the narcotics. I think they are not always prescribed properly and we have a public who seems to think they are entitled to be pain free.